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QUALITY CONTROL in ESTHETIC DENTISTRY Gerard Chiche L.L.C.
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1. PROPER LENGTH SMILE BUILDER 2. DOMINANT CENTRALS
3. CONVEX SMILE LINE 4. INCISAL EMBRASURES 5. HIGH BRIGHTNESS SMILE BUILDER
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WHAT ARE THE STEPS. 1. Road map 2. Parameters 3. Confidence Builder
WHAT ARE THE STEPS? Road map Parameters Confidence Builder SEVEN OBJECTIVES
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No Direct, indirect income or royalty from products discussed except
DISCLOSURE Dept. Grants & Funding, Honorarium 3M-ESPE, Vident, Brasseler USA Nobelbiocare, 3I, Zimmer No Direct, indirect income or royalty from products discussed except Paid Consultant NORITAKE co. Teaching Faculty & Former Consultant PANKEY INSTITUTE
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DISCLAIMER Techniques and principles reviewed in this all-day program are derived from my personal teaching and clinic experience. They do not constitute a guarantee for success , the attendees should form their own opinion. Gerard Chiche L.L.C.
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I INCISAL PLANE
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Preview Length Adjustment
Incisal Plane Convex Flat Concave Too Convex Preview Length Adjustment
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SMILE LINE Record Shape 2. Record Lower Lip
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Edge to Edge Pitch of the upper anterior teeth should mirror the pitch of the lower anterior teeth
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1. Harmonize Anterior Guidance
PRECAUTIONS WITH SMILE LINE 1. Harmonize Anterior Guidance 2. Harmonize Pitches and Bevels 3. Smooth Crossover
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II INCISAL PROFILE
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PLAN Incisal Length 2. Gingival Level Implant Level
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INCISAL PROFILE 1. Harmony with Lower Lip Perpendicular Relation + Final Restoration
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III INCISAL LENGTH
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Pleasing Display 3.5 - 4.5 mm. Pleasing Length 10 - 11 mm.
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INCISAL LENGTH 1. Measure Display 2. Measure Length
Test Drive New Envelope Do not Steepen Guidance when Increase Length without testing
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IV TOOTH PROPORTION
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Short-Fat Proportion Never Engineer Narrow-Long Proportion
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PLAN Preview 2. Check against Face 3. Involve Lat. & Can.
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Mesial Additions Fat Central Incisor Distal Reductions
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Proportion Display Length
RULE Priority = Centrals Proportion Display Length
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RULE Create Reference Points
Display Length : At least 10 mm. 3. Width: At least 7.5 mm. 4. Midline : Must be Vertical Lateral Incisor: 2mm. rule 6. Canine: 1mm. rule
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10 mm. L mm 11 mm. L mm
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Central Incisors At Least 7.5 mm Width
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V TOOTH to TOOTH PROPORTION
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TOOTH-TO-TOOTH PROGRESSION Main Test ? DELICATE Lateral Incisor
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PROPORTION CONTROL Precautions
Implants Short Papillae Canine Substitution Orthodontic Planning
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LATERAL INCISOR IMPLANT
Deficient Papillae = Use Special Effects
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1. Decrease Reflection 2. Increase Deflection 3. Round Flatten
SPECIAL EFFECTS 1. Decrease Reflection 2. Increase Deflection 3. Round Flatten
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Lateral Incisor Design
1. Does not Compete for Attention 2. Deficient Papilla = Special Effects 3. Canines in Lateral Position = Keep Centrals dominant 4. Lat. I. = CI-2mm., Can. = CI-1mm. 5. 70% Ratio for Normal Size Teeth
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Pract Proced Aesthet Dent 2007; 19 (4)
54 patients (36 F) (18 M) years Average width 8 and 9 : 8.5 mm. 7 and 10: 6.5 mm. 6 and 11: 7.5 mm. Range for central incisors: 7.1 – 9.62 (8) and 7.32 – (9) Range and Mean Distribution Frequency of Individual Tooth Width of the Maxillary Anterior Dentition S. J. Chu Pract Proced Aesthet Dent 2007; 19 (4)
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VI GINGIVAL PLANE
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SYMMETRY 1. Level against Face 2. Set Pleasing Ref. Level
3. Set Pleasing Ref. Line
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VII DESIRED FULLNESS
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FULLNESS 1. Show on screen first 2. Mandibule Angle
3. Provide Canine Disclusion Allow Cusps Escape
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WHAT ARE THE STEPS ? 1. Record Shape 2. Phonetics, Occlusal Plane
3. Measure Display, Length 4. Record Proportion, Width 5. Delicate Lateral Incisor 6. Symmetry, Progr., Lip 7. Patient’s Desires, Cost
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GINGIVAL PLANE Follows UPPER LIP LINE
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Break Time
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ALL-CERAMIC CROWNS
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REALITY RATINGS 2009 IPS Empress Ivoclar 1. Lava 3M Espe Cerabien Noritake HeraCeram Heraeus 4. EX-3 Noritake 5. IPS D.Sign Ivoclar 5. Omega 900 Vident Duceragold Dentsply VM7 / VM9 Vident 6. Creation Jensen 6. Finesse Dentsply
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I WHAT SYSTEM ?
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ALL CERAMICS TWO FAMILIES = TWO LOGICS
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ALL CERAMICS FAMILY A
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FAMILY A ALUMINA ZIRCONIA
“…The alumina particles did not show any surface alteration by the etchants...” Della Bona A. & Anusavice K
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.Degussa Allceram Ceram S
.Noritake Cerabien CZR, CZR Press .Jensen Creation AV Lava Ceram .Vident Alpha, VM7 VM9 .Nobelbiocare Rondo Rondo Zirconia .Ivoclar EMax
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ALL CERAMICS FAMILY B Etchable Crowns
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Empress Esthetics Emax Lith. Disil.
Authentic CZR Press Duceram LFC Finesse ProCad Mark II Examples
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II WHAT CEMENT ?
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REALITY RATINGS RESIN GLASS IONOMERS LUTING
FUJI PLUS 1 . FUJICEM AUTOMIX 2 . RELY X LUTING PLUS RELY X LUTING FUJICEM KETAC-CEM 2009
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Shear Bond Strength to LAVA
9 MPA 6 MPA FUJICEM MAXCEM NEXUS 2 UNICEM Shear Bond Strength of Self-Adhesive Resin Cements: A comparative Study R. Aljouni et al, 2006 (Abstract 329)
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WHY Adhesive Cementation ? Suggested Reasons include
1. Increase Retention 2. Increase Strength 3. Decrease Microleakage 4. Best for Thin Cores
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Prep. Height Zinc Phosh. Panavia F
Mean Cycles to Failure Prep. Height Zinc Phosh. Panavia F 2 mm. 9, , mm , , mm , , mm , ,000 The Effect of Preparation Height and Luting Agent on the Resistance Form of Cemented Cast Crowns under Load Fatigue. E.W. Lepng et al. J. Prosthet Dent 102: 155 , 2009
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Blatz, Oppes, Sadan, Chiche. Quint Int. 2008
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M.B. Blatz 2003 SBl. (10 sec.) 11.58 Mpa (4.13) Rocatec soft+Silan
SBl +CPA / CSE 16.58 Mpa (3.17) LAVA Zirconia (6 months testing) M.B. Blatz 2003
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REALITY RATING / DUAL CURE
1 . INSURE / INSURE LITE 2 . NX3 VARIOLINK II VITIQUE LUTE-IT! CALIBRA 1 . RELYX UNICEM 1 . EMBRACE WETBOND 1. G-CEM SMARTCEM 2 2, BISCEM 3. MAXCEM ELITE 1 . PANAVIA F 2.0 2 . MULTILINK AUTOMIX 3. CLEARFIL ESTH. CEM. 4. BISTITE II DC 1 . RELY X ARC 2 . DUO-LINK 3. CEMENT-IT! 2009
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“Ceramic material and bond quality significantly influence the load bearing capacity of leucite and Lithia-disilicate ceramic restorations… This clearly demonstrates the importance of the relationship between the adhesive process and the overall strength of the restoration”. Influence of Bond Quality on Failure Load of Leucite- and Lithia disilicate-based Ceramics N. L. Clelland et al. J. Prosthet Dent. 2007; 97:18
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No etch, no silane. Unicem. 9. 6 +-1. 9. Multilink. 6. 2 +-1. 2
No etch, no silane Unicem Multilink Panavia F Doubles If etch and silane Unicem Multilink Panavia F Influence of ceramic surface conditioning and resin cements on microtensile bond Strength to a glass ceramic. J. Pisani-Proenca et al. J. Prosthet Dent. 2006; 96:412
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Auto Pol. Light Pol. Rely ARC. 96. 1 (14. 3) 131. 2 (21
Auto Pol. Light Pol. Rely ARC (14.3) (21.7) Unicem Translucent (114) (19.6) Unicem A (5.9) (18.2) Maxcem Clear (9.5) (10.8) Maxcem Yellow (8.3) (17.7) “…All dual-cured cements both self-etch and conventional showed highly superior properties when photopolymerized … One self-etch cement revealed a unique rapid rise to neutrality in both dual-cure and self-cure mode…” E. Saskalauskaite et al Flexural Strength, Elastic Modulus and pH profile of Self-etch Resin Luting Cements. J. Prosthodontics 2008: 262
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Bond Strength, f Self-adhesive Cementing agents to dentin and enamel
Bond Strength to Enamel (Unetched) Rely Unicem Aplicap (2.0) Rely Unicem Clicker (2.8) Maxcem (3.3) A. Piwowarczyk et al Bond Strength, f Self-adhesive Cementing agents to dentin and enamel IADR Abstract 2007 #1540
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1. Etch 2. Silane 3. Light-Cure 4. Neutral Shade
Glass Ceramics 1. Etch 2. Silane Dual-Cure Cements 3. Light-Cure 4. Neutral Shade Marginal Enamel Etch in selective situations (Varies with Cement – Check with manufacturer first)
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III WHAT PRECAUTIONS ?
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Procera Crowns – 26 Mo. . Failures : 1 Decay, 6 veneer fractures. Survival of Procera AllCeram Ceramic Crowns in Students Clinics. J. Hochstedler et al. 2004
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Marginal Ridge Support Anatomical Cores
Core Integrity Short Preparations Marginal Ridge Support Anatomical Cores . Survival of Procera AllCeram Ceramic Crowns in Students Clinics J. Hochstedler & A. Sadan 2004
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Adequate Support May Increase Restoration Strength by 30%
Fischer et al. JIADR 2006, Abstract 546 “…Copings for crowns must be designed to minimize tensile loading of veneering porcelain…” Marschak et al. J Prosthet Dent 2008 99: 169
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Raigrodski AJ, Chiche GJ, Potiket N, Mohamed SE,
Hochstedler JL, Mercante DE, Billiot S. The efficacy of posterior three-unit zirconia-based bridges A prospective pilot clinical study J Prosthet Dent 2006;96:237-44
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ZIRCONIA FPD 1. Patient Selection Insure Thick Connectors
Facial Shoulder 4. No Lateral Interferences Fine Diamonds – Reglaze Slow Cooling Cycle Zirconia – Veneer Interface
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IADR 2007, # 0885 J Dent. Research Vol 86, Special Issue A
Chamfer Preparation 21 mic. (6 mic.) Shoulder Preparation 11 mic. (6 mic.) Difference was significant. Marginal Fit of Zirconia Crown Copings on chamfer and Shoulder preparations IADR 2007, # 0885 J Dent. Research Vol 86, Special Issue A D. Augusti, G. Augusti
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Effect of veneering Techniques on Damage and Reliability
Shear Bond Strength of Veneering Ceramics to Zirconia J Dent Res 2006;85:Abstr 0888 Blatz MB, Chapman L, et al Effect of veneering Techniques on Damage and Reliability of Y-TZP Trilayers European J Esthet Dent 2009;4-3 P. Guess Zirconia Posterior Fixed Partial Dentures Prospective Clinical 3-Year Follow-up Int J Prosthodont 2009;22:597 Schmitt J, et al
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ZIRCONIA CERAMICS FPD’S SIMILAR 3-YR
SURVIVAL RATE TO METAL CERAMIC FPD’S Int. J Prosthodont; 2009; 22: 553 Sailer I. et al 100% RETENTION at THREE YEARS PRECAUTIONS WITH SECOND MOLARS Int. J Prosthodont; 2009; 22: 597 Wichan & Holst No NEW CHIP SINCE FIRST YEAR J Prosthet Dent 2006;96:237-44 Raigrodski AJ, et al
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Main Precautions 1. Patient Selection Insure Thick Connectors
Facial Shoulder 4. No Lateral Interferences Fine Diamonds – Reglaze Slow Cooling Cycle Zirconia – Veneer Interface
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IV CERAMIC SELECTION
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CRITERIA Alumina / Zirconia . 1 Discolored Teeth
No Bonding Requirement Need Adequate Thickness Thinner Cores on Facial CRITERIA
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CRITERIA Etchable Crowns 1 Best Translucency
2 Reduced Facial Thickness May be Equigingival 4 Plan Masking Strategy CRITERIA
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DISCOLORATIONS & SYSTEM SELECTION 1. CREATE BONUS SPACE MATCHED PAIRS INGOT SELECTION AVOID EXCESSIVE TRANSLUCENCY
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“The Common Denominator must NOT be the most discolored tooth”
M. Roberts
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V OCCLUSAL PRECAUTIONS
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DETERMINE ANTERIOR GUIDANCE
Test-Drive New Envelope. 2. Transfer Existing Guidance. 3. Custom Guide Table. 4. Half try-in when Feasible. Passive Anteriors – No Fremitus Static: 3 positions & Dynamic: Chew 6. Maintain Guidance if shorten.
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Protection Strategy Assess Risk
Discover What they are Likely to do with their Teeth Do not Put Teeth in the Way of Habitual Function and Envelope of Parafunction J. Fondriest & M. Fling
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… : Move Tooth to Safe Position First …: Shallower Cuspid Guidance
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The flatter the angle of guidance, the lower the muscle activity.
G. Williamson J. Prosthet Dent 1983 For every 100 change in the angle of disclusion, there is a 35% change in force applied. L. Weinberg
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“…The resultant closure forces of the mandible are upward and forward
“…The resultant closure forces of the mandible are upward and forward. This produces a mesial force between the interproximals resulting in anterior teeth more vertical and a constricted envelope…” T. Tanaka 2008
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VI PORCELAINVENEERS
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FRIEDMAN M.J. A 15-Year Review of Porcelain Veneer Failure A Clinician’s Observations COMPENDIUM. 19, 1998
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FAILURES (7%) 1. FRACTURES (67%) 2. MICROLEAKAGE (22%) 3. DEBONDING (11%)
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Cervical Dentin + Heavy Occlusion
LONG-TERM BONDING Cervical Dentin + Heavy Occlusion = CONTROL FLEXURE
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Canines Management Contact Intensity Contact Location 3. Steepness of Guidance
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VII PREPARATION SYSTEM
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. LVS LVS
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Castelnuovo J. et al. J. Dent. Res. 77; Abstract 1373
INCISAL REDUCTION Unrestored Tooth 2 mm. 4 mm. FRACTURE STRENGTH 31.0 Kg. (10.38 s.d.) 27.4 Kg. ( 9.63 s.d.) 19.2 Kg. ( 6.18 s.d.) Fracture Strength and Failure Mode for Different Ceramic Veneer Designs. Castelnuovo J. et al. J. Dent. Res. 77; Abstract 1373
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“Maxillary restored with the 3 types of IPS Empress 1 Veneers showed fracture resistance similar to that of unprepared incisors …” Longevity and Failure Load of Ceramic Veneers with Different Preparation Designs after Exposure to Masticatory Stimulation C. F. J. Stappert et al J. Prosthet. Dent. 2005, 94,
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VIII VENEER SELECTION
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Making a Six-Unit Smile Design “Disappear” in the mouth
using feldspathic porcelain B. Jones Jrl. Cosmetic Dentistry 2007, 22 (4) Conservative Aesthetic Enhancement of the Maxillary Anterior Using Porcelain Laminate Veneers. J.M. Lerner Pract Proced Aesthet Dent 2006; 18 (6) Permanent Diagnostic Provisional Restorations for Predictable Results when Redesigning the Smile. G. Gurel, N. Bichacho Pract Proced Aesthet Dent 2006; 18 (5)
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Pressed vs. Feldspathic Veneers
1. P Combination with Crowns. 2. P Complex Occlusal Rehabs. P Better Cost. F Better Esthetic. F More Conservative, No Prep. 3. F Contact Lens Effect, Varying Trsl
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IX SHADING SYSTEM
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A.J. Raigrodski & G.J. Chiche. 2004
Efficacy of a computerized shade selection system in matching anterior metal-ceramic crowns. A double-blind clinical pilot study. A.J. Raigrodski & G.J. Chiche. 2004
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Cervical Shade Incisal Shade Basic Shade Mix Colors Two Tabs
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SHADING EFFECTS CHECKLIST
HALO TRANSPARENT STREAKS PROXIMAL CLEAR
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Incorporate for Natural - Driven Incisal Effects Soften or Eliminate for Perfect - Driven
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Bleached Shades A B M M3 0M2 NW05 NW0 BL3 BL2 PW4 PW7
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X CLINICAL VARIATIONS
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Set Goals . Increase Brightness Increase Length Fuller Smile
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INCREASE FULLNESS 1. Set Perpendicular Relation +. 2
INCREASE FULLNESS Set Perpendicular Relation Check Harmony with Lip
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INCREASE LENGTH and FULLNESS
Mock-up for Length Wax-up for Fullness Instant Mock-up 4. Show First on Screen ! Preparation Guide Always Augment 7. Verify Gingival Levels
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1. Preop. Silicone Impression 2. Undercontour Cervical Wax
VENEER PROVISIONALS 1. Preop. Silicone Impression 2. Undercontour Cervical Wax 3. Duplicate Wax-up, Pour Model 4. Score Cervical with Cleoid 5. Spot Etch & Bond Preps 6. Fill Matrix with Bis-Acryl 7. Trim with ET3, ET4 & #12
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6 mm 56% 7 mm 27% Contact to Bone crest Interdental Papilla
Base of Proximal Presence of Contact to Bone crest Interdental Papilla 5 mm % 6 mm % 7 mm % The effect of the distance from the contact point to the crest of bone on the presence or absence of the interproximal dental papilla D. Tarnow et al 1992
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Following Denudation Procedures
“… Results showed a mean distance of 4.33 mm. between the location of the gingival margin post-treatment and the bone level during surgery…” Regeneration of the Interdental Soft Tissues Following Denudation Procedures U.Van Der Velden 1982
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Healthy Papilla = 5 mm. Healing Papilla = 4 mm. J. Kois
PAPILLA HEIGHT Healthy Papilla = 5 mm. Healing Papilla = 4 mm. J. Kois
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2. 4 mm Esthetically Acceptable
PAPILLA “COME BACK” Short Papilla < 4 mm 2. 4 mm Esthetically Acceptable Healing from Trauma 3 QUESTIONS
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1. Maximize Symmetry 2. Special Effects 3. Unilateral Pair
D. Tarnow 2004
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Unilateral Pair 1. Select Cantilever 2. Forced Eruption
3. Sequential Placement Interimplant Papilla Preservation in the Esthetic Zone. Report of six consecutive Cases J. Kan, K. Rungcharassaeng Internaltional J. Perio Restor Dent 2003; 23 (3)
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Advanced Esthetics & Interdisciplinary Dentistry 2006; 2 (3)
Forced Eruption “…0.5 mm to 1 mm. per month of eruption and then maintain this position 1 month for each millimeter of coronal movement…” Advanced Esthetics & Interdisciplinary Dentistry 2006; 2 (3)
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XI BONDING UPDATE
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REALITY RATING LIGHT CURE DUAL CURE LIGHT CURE ONLY
1 . INSURE / INSURE LITE 2 . NX3 2. VARIOLINK II 3. VITIQUE 4. LUTE-IT! 5. CALIBRA 1 . RELY X VENEER CEM. 2 . VARIOLINK VENEER 3. DA VINCI 4. ACCOLADE PV 5. CHOICE 2 2009
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Clear White (Thin Veneers)
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8 Authentic Block pairs all air abraded and etched with HF
“…Omission of the post-etching cleaning resulted in more than 50% loss in bond strength Influence of post-etching cleaning and connecting porcelain on the microtensile bond strength of composite resin to feldspathic porcelain. P. Magne and D. Cascione J. Prosthet Dent. 2006; 96:354
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BONDING PRECAUTIONS 1. Rubber Dam 2. Glistening Preparation
Agitate Primers Evaporate Solvent J. Burgess 2005
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XII PROTECTION STRATEGY
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Functional Considerations
MIP coincident with CR Night-time Appliance Envelope of Function Custom Guide Table Dentin Bond Technique Porcelain Selection Incisal Extension
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J. Kois, B. Filder. Compendium, 30; 7: 420 September 2009
Three-Dimensional Assessment of Dental Occlusion. (Occlusal Fencing) A Clinical Technique. N. Mehta, E. Abdallah et al , Advanced Esthetics & Interdisciplinary Dentistry Clinical Case Report. Anterior Wear: Orthodontic and Restorative Management. J. Kois, B. Filder. Compendium, 30; 7: 420 September 2009
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Deep Bite Bulky Crowns Over-retracted Misalignment Retrusion
Restricted Envelope Deep Bite Bulky Crowns Over-retracted Misalignment Retrusion S. Ratcliff
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Optimize Anterior Guidance
Constriction Involved ? 2. Crowns with Proper envelope 3. Reposition Teeth before Veneers Restore or Increase VDO Occlusal Guard
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THANK YOU
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